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| ORIGINAL ARTICLE |
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| Year : 2019 | Volume
: 3
| Issue : 4 | Page : 161-164 |
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Treatment patterns of patients with schizophrenia based on the data from 44,836 outpatients in Russia
Karel Kostev1, Galina Osina2, Marcel Konrad3
1 Depatment of Epidemiology, IQVIA, Frankfurt, Germany
2 Real World Evidence,IQVIA, Moscow, Russia
3 Health & Social, FOM University of Applied Sciences for Economics and Management, Frankfurt, Germany
| Date of Submission | 23-Oct-2019 |
| Date of Acceptance | 26-Nov-2019 |
| Date of Web Publication | 23-Dec-2019 |
Correspondence Address:
Dr. Karel Kostev
IQVIA, Unterschweinstiege 2.14, 60549 Frankfurt
Germany
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/hm.hm_73_19
Aim: The goal of the present study was to estimate the treatment patterns in outpatients with schizophrenia in Russia. Methods: A total of 44,836 outpatients with schizophrenia treated by 812 psychiatrists in 2018 were selected in the LRx database in Russia. We descriptively analyzed the proportions of patients treated with different therapy classes and drugs. Results: Typical antipsychotics (58.2%) were the therapies with the highest patient proportion, followed by anti-Parkinson drugs (38.3%) and antidepressants (30.6%). The most frequent anti-Parkinson drug was trihexyphenidyl; the most frequent antidepressant was amitriptyline. Conclusions: The findings of this study imply that the proportion of older drugs is higher in schizophrenia therapy in Russia than reported based on samples in Europe and the U.S.
Keywords: Antidepressants, antiepileptics, antipsychotics, benzodiazepine, Russia, schizophrenia
How to cite this article:
Kostev K, Osina G, Konrad M. Treatment patterns of patients with schizophrenia based on the data from 44,836 outpatients in Russia. Heart Mind 2019;3:161-4 |
| Introduction | |  |
Schizophrenia is a severe psychiatric disease with a relatively small prevalence of about 0.3% but a very high burden.[1] The prevalence of schizophrenia differs slightly between countries.[2] Some large countries like Russia have no published studies on the prevalence of schizophrenia among the general populations. Based on about 140 million inhabitants in Russia, it can be assumed that about 400,000 people live with schizophrenia in this country. Shaposhnikov and Sitchikhin reported that 354,790 patients with schizophrenia with a high degree of disability were registered in 2013 in Russia.[3]
With no cure for schizophrenia, the main goals of schizophrenia treatment include symptom targeting and relapse prevention.[4] Pharmacological therapy plays a very important role in the treatment of this disease, and several mono- and combination pharmacological therapies are available for treating schizophrenia symptoms. Antipsychotics are the first choice among psychotropic agents used to treat schizophrenia. For some patient groups, treatment strategies include the combination of neuroleptics and antiepileptics.[5] As the prevalence of depressive symptoms in patients with schizophrenia is relatively high, antidepressants are also often prescribed.[6] Moreover, some evidence supports the use of combination therapy with antipsychotics and benzodiazepines.[7] Finally, the use of certain anticholinergic drugs in conjunction with antipsychotics has been identified as an important topic in the treatment of schizophrenia.[8]
In recent years, several studies on real-world prescription patterns in schizophrenia have been published, which have enabled the evaluation of the efficacy and safety of therapy practices. Such studies were performed in the U.S,[9],[10],[11] China,[12] Japan,[13] Germany,[14] and seven Eastern European countries, including Croatia, Estonia, Hungary, Poland, Serbia, Slovakia, and Slovenia.[15] The methods and patient populations differed between the countries, but each study was an important investigation into the epidemiology of schizophrenia. Nevertheless, there are no studies that investigate the complete treatment patterns of outpatients with schizophrenia in Russia.
The goal of the present study was to estimate the treatment patterns in outpatients with schizophrenia in Russia, including all therapy classes prescribed to these patients.
| Methods | | |
This retrospective cross-sectional study was based on the IQVIA Russia LRx database, which covers approximately 11% of all patients enrolled in federal or regional reimbursement state health-care programs. The data are properly anonymized (in accordance with federal law 152) and allow for longitudinal tracking of each patient via a unique patient ID. Other data attributes include age, sex, diagnosis, and prescription information (therapy with the indication of trade name, molecule, drug form, dosage, and manufacturer, region in which the drug was dispensed; prescription period) and prescriber specialty.
Patients with at least one prescription to treat schizophrenia (ICD-10: F20) from 812 psychiatrists in the time period between January 2018 and December 2018 were included in our analyses. No exclusion criteria were used. We analyzed the following therapy classes based on the anatomical classification of pharmaceutical products published by the European Pharmaceutical Market Research Association: atypical antipsychotics (Anatomical Therapeutic Chemical [ATC]: M05A1), typical antipsychotics (ATC: N05A9), antidepressants (ATC: N06A), antiepileptics (ATC: N03), benzodiazepines (N05C), and anticholinergic anti-Parkinson drugs (ATC: N04A).
We separately analyzed the proportions of patients with schizophrenia treated with each of these classes, both by monotherapy and combination therapy. Monotherapy was defined as the prescription of only one therapy class during the study period. Combination therapy was defined as the prescription of at least two of these classes in the same month (as no prescription days are available in the database). When a patient received several therapy combinations in different months throughout the year, the most recent combination was analyzed. In the second step, we analyzed the drugs prescribed to patients with schizophrenia.
This study is of a descriptive nature, and no hypotheses were tested. All analyses were carried out using SAS version 9.4 (SAS Institute, Cary, NC).
| Results | | |
A total of 44,836 patients with schizophrenia who received medication therapy were available for the analysis. The mean age was 43.4 years (standard deviation [SD] 4.7 years) and 49.5% were women [Table 1]. Among all of them, 80.0% were treated with antipsychotics, with 58.2% receiving typical and 28.3% atypical antipsychotics [Figure 1]. The therapy with the highest patient proportion was typical antipsychotics, followed by anti-Parkinson drugs (38.3%) and antidepressants (30.6%). | Table 1: Basic characteristics of patients with schizophrenia in this study
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 | Figure 1: Therapy classes prescribed to patients with schizophrenia in Russia in 2018. Monotherapy was defined as the prescription of only one therapy class during the study period. Combination therapy was defined as the prescription of at least two of these classes in the same month (as no prescription days are available in the database). When a patient received several therapy combinations in different months throughout the year, the most recent combination was analyzed
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Anti-Parkinson drugs were prescribed to 42.0% of the patients treated with typical and 27.4% of the patients treated with atypical antipsychotics.
Antiepileptics were prescribed to 13.3% of the patients. Furthermore, only 13.5% of the patients received benzodiazepines as their current therapy [Figure 1], but 24.5% had received benzodiazepines at least once in 2018. Typical and atypical antipsychotics were the two therapy classes most often given as monotherapy, while the other therapy classes were mainly given in addition to antipsychotics [Figure 1].
When these drugs classes were prescribed at least one time, the mean numbers of prescriptions per patient during the year were as follows: atypical antipsychotics: 4.3 (SD: 2.9), typical antipsychotics: 4.5 (SD: 3.1), antidepressants: 4.0 (SD: 3.0), anti-Parkinson drugs: 4.6 (SD: 3.2), and benzodiazepines: 2.9 (SD: 2.4).
In patients treated with typical antipsychotics, haloperidol (30.2%), zuclopenthixol (16.3%), and chlorprothixene (13.7%) were the three most frequently prescribed drugs. Among atypical antipsychotics, clozapine (86.9%), risperidone (13.1%), and quetiapine (17.2%) were most frequently prescribed. Other relevant drugs were trihexyphenidyl (86.9% of the patients treated with anti-Parkinson drugs), amitriptyline (37.1% of the patients treated with antidepressants), phenazepam (85.2% of the patients treated with benzodiazepines), valproate (42.1% of the patients treated with antiepileptics), and carbamazepine (40.7% of the patients treated with antiepileptics) [Figure 2]. | Figure 2: Drugs with a schizophrenia patient proportion of at least 10% of the therapy class. The denominators are patients with schizophrenia who have used that class of medication. For example, presumably, 85.2% of those prescribed benzodiazepines received phenazepam
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| Discussion | | |
Main findings
In this retrospective study of almost 45,000 individuals with schizophrenia, we found that the majority patients received antipsychotics. Typical antipsychotics were more frequently prescribed than atypical antipsychotics. The most common combination therapy included anti-Parkinson drugs and antidepressants, and the majority of patients received older generations of drugs.
Interpretation of the findings
One of the main findings of this study was the high proportion of patients treated with typical antipsychotics and the lower proportion of patients prescribed atypical antipsychotics. Some studies have shown that atypical antipsychotics are more beneficial than conventional drugs for cognitive dysfunction and also have fewer side effects.[16],[17] The few eligible trials suggested that clozapine may be more effective than other antipsychotics when used as first- or second-line treatment.[18]
Anticholinergic drugs are often used to reverse extrapyramidal symptoms that result from antipsychotic drug use. The prevalence of such symptoms is higher in patients receiving typical antipsychotics than in patients receiving atypical antipsychotics.[19] In the present study, anti-Parkinson drugs were given much more frequently to patients treated with typical antipsychotics than to patients treated with atypical antipsychotics, which may indicate that a higher proportion of patients treated with typical antipsychotics had extrapyramidal side effects. However, typical antipsychotics, as an older antipsychotic generation, are much more affordable and therefore have a higher share in the reimbursement segment.
Interestingly, the most frequently prescribed anti-Parkinson drug was trihexyphenidyl. This drug was shown to be effective in preventing or treating the extrapyramidal side effects of antipsychotics. However, anticholinergics can cause central adverse effects, which is why psychiatrists in Europe only rarely prescribe trihexyphenidyl today.[8] Anti-Parkinson drugs were not only prescribed in a high share of schizophrenia patients but also prescribed on average approximately five times/year. This prescription pattern is not usual, as these drugs are associated with several side effects.
The proportion of benzodiazepine prescriptions in patients with schizophrenia in Russia (24.5%) was slightly lower than the shares reported for the U.S. and Switzerland. Schuster et al. reported that the prevalence of benzodiazepine use was 29.8% in older patients with schizophrenia in Switzerland.[20] In the U.S. study, 27.5% of patients with schizophrenia were prescribed benzodiazepines as monotherapy or in addition to antipsychotics.[21] However, the prescribed drugs differ from country to country (phenazepam in Russia and diazepam and lorazepam in Europe and the U.S, respectively). Phenazepam is a benzodiazepine developed in the former Union der Sozialistischen Sowjetrepubliken (USSR) about 50 years ago and its toxicity is considered to be lower than that of other benzodiazepines. This drug has been often been prescribed in Russia for anxiolytic, sedative-hypnotic, or antiepileptic uses.[22]
The prevalence of antidepressant use in patients with schizophrenia has been reported in several studies.[23] The average prevalence of depressive symptoms in patients with schizophrenia is estimated to be about 25%. In a U.S. study by Himelhoch et al., 37% of patients with schizophrenia received antidepressants.[24] In Italy, a proportion of 40% was reported.[25] In Eastern European countries, 42% of patients with schizophrenia received antidepressants.[15] The prevalence of antidepressant use in the present study was 30.6%, which does not considerably differ from other published studies. However, the antidepressant drug class that was used was different. In the U.S., the share of selective serotonin (noradrenalin) reuptake inhibitors (SSRI/SNRI) was 85%,[24] in Italy, it was 55%,[25] and in Russia, it was 42.1%. Again, the reason may be the higher price of SSRI/SNRI therapy compared to such older antidepressant drugs as tricyclic antidepressants.
Strengths and limitations
The two major strengths of this study are the large sample size and the use of a pharmacy database. However, the findings of this study should be interpreted in the light of several limitations. First, as LRx is a prescription database, only treated patients could be analyzed, which can cause the prevalence of the use of defined drug classes to be overestimated. Moreover, the coverage of the data is 11%, and it is possible that patients in the covered regions have demographic, clinical, and therapy-related differences to patients in the noncovered regions. Second, this was a retrospective study, and missing data on disease severity and/or therapy compliance may have biased the subsequent descriptive analyses. Third, only pharmacological therapy was analyzed, as no data on psychotherapy were available. Finally, schizophrenia treatment patterns were analyzed in Russia, and these findings cannot be extrapolated to populations in other countries.
| Conclusions | | |
The drug classes prescribed to outpatients with schizophrenia in Russia do not differ from those given in Europe or the U.S. However, the findings of this study imply that the proportion of older drugs in Russia is higher than reported based on samples in Europe and the U.S. Further studies are needed to identify the reasons why older generation drugs are prescribed in Russia.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1]
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